Back In The Mouths Of Babes

It's a sunny spring afternoon, and Dr. Kathleen Marinelli is seated in her small, neat office at Connecticut Children's Medical Center, working rapid-fire on a set of feeding and anesthesia guidelines for breastfed babies undergoing surgery.

On the wall to her right hang three framed black-and-white photos of a mother nursing her tiny premature infant. A sign on the door in her daughter Katie's second-grade print reads, "I love you my beloved bill poser ...Love Katie Alex Ethan Caroline." "Poser," a misspelling of "passer," is a reference to Marinelli's role in shepherding a state breastfeeding law through the legislature last year.

The rest of her office décor is given over entirely to her family. Snapshots of her husband, Mark Bamberger, and four children fill the bulletin board over her desk and framed pictures line the back of every horizontal surface. "People think these are my patients," she says, grinning. "I figure if I have to spend 12 hours at a shot in this office or in this building, I might as well be able to see my kids." Some days, like this one, that 12 hours extends to 14 or 16, and she and Bamberger, a research scientist at Pfizer, are reduced to communicating by voice mail and email.

In the six hours since Marinelli arrived this morning, she has answered a slew of phone messages, emails and letters, firmed up arrangements for the state's annual Physician's Conference on Breastfeeding Medicine, made her first rounds of the neonatal intensive care unit and worked one on one with two mothers who are having trouble getting their babies to breast. Now, after downing a quick can of soup at her desk, she is gearing up for the heart of her day - another six hours on the unit. After that, she'll attend a dinner meeting of the American Academy of Pediatrics' state breastfeeding committee - which she chairs - where she will linger past midnight, talking about her favorite subject.

Marinelli, a neonatologist who has earned a reputation as the hospital's "breastfeeding guru," is passionate about her mission, and it seems to give her boundless energy.

Nearly 6 feet tall, Marinelli, 42, is at once all business and all warmth - her physician's precision and maternal instinct blending into a powerful force that wants to tackle every problem and help every person. Her short brown hair is layered gently away from her face, and the long sleeves of her soft, teal dress are pushed up past the elbows, ready for work. Her pager and ID tag are clipped to her hip pocket, and a pair of gold reading glasses hangs from a slim black cord around her neck. Her speech, like her face, is animated. She has a habit, when amused, of sticking out her tongue and biting it. She does everything fast - talk, walk, type, write. "It's the only way I get everything in," she says.

For decades, the only really audible voice for breastfeeding in the United States was La Leche League, an international grassroots organization often marginalized as militant by the mainstream. Now, the message is trumpeting forth from all sorts of podiums, thanks to new scientific research that reveals the far-reaching and complex benefits of breastfeeding, and the rise of women like Marinelli into positions of power.

The bill she helped draft and push through the Connecticut legislature last summer is a prime example. It protects women's right to use break time on the job to breastfeed or express breast milk and requires employers to make reasonable efforts to provide a private space other than a toilet stall for that purpose. In 1997, the state passed a separate bill guaranteeing women the right to nurse their babies without harassment in any public or private place they are authorized to be, after a Milford mother was threatened with arrest while breastfeeding in her car.

Similar legislation has popped up all over the country. More than half of all states have passed at least one law protecting breastfeeding women, and two separate bills are sitting in committee in the U.S. House and Senate that would give breastfeeding mothers protection under the Civil Rights Act. The House bill also provides tax incentives to employers who support breastfeeding.

The movement seems to be taking off. This summer more than 1,000 women set a world record with a mass breastfeeding in Berkeley, Calif. And in the past year, "nurse-ins" have been held in New York, Maryland, California and elsewhere to protest incidents of harassment or discrimination.

A growing body of evidence testifies to the unique benefits of breastfeeding, for both mother and child. "It has become increasingly apparent that infant formula can never duplicate human milk," notes an article on the Food and Drug Administration website, quoting a scientific study. "Human milk contains living cells, hormones, active enzymes, immunoglobulins and compounds with unique structures that cannot be replicated." Breastfeeding lowers the risk of respiratory illness, infection, diarrhea, allergies and obesity. The distinctive sucking pattern it requires is especially suited to oral development. And chemical changes in nursing mothers have been shown to bring on feelings of relaxation and love, help return the womb to its pre-pregnancy state and lower the lifetime risk of uterine and breast cancer. In fact, a new British study has found a direct correlation between the number of months a woman breastfeeds and the drop in her risk of breast cancer. While infant formula - generally built on a base of cow's milk, whey, or soy and vegetable oils - has become increasingly sophisticated in response to new research, it will always be "second best," as the FDA site puts it.

The benefits of breastfeeding translate to reduced health-care costs for both mother and baby, and federal agencies - from the Department of Health and Human Services to the Centers for Disease Control - have now joined the chorus advocating exclusive breastfeeding through the first six months of life and continued breastfeeding through at least the first year. Backed by the strength of those recommendations and similar ones from the World Health Organization, UNICEF and the American Academy of Pediatrics, breastfeeding advocates in the U.S. are finally making significant progress.

"It's a very exciting time to be involved in breastfeeding because things are moving forward and there are people who are interested, so you can make an impact now," says Marinelli. But, "we still have a very long way to go."

Though 64 percent of mothers nationwide initiate breastfeeding, by six months after birth, the rate has fallen to 29 percent, and by one year, to 16 percent. The rates are much lower among African American women and mothers receiving assistance through the federal Women, Infants and Children program, which offers free formula vouchers as part of its food package.

Those statistics have special meaning in a city like Hartford, with the highest rate of births to single mothers in the nation - 78 percent in 1998, according to Child Trends and Kid Counts. A fifth of all city births in 2000 were to teens, with more girls giving birth here than graduating from high school, according to Breaking the Cycle, the city's teen pregnancy prevention campaign. These are exactly the women and babies who have the most to gain, physically, emotionally and financially, from breastfeeding and are the least likely to pursue it.

Marinelli, like others in the breastfeeding community, understands that creating change means tackling the issue on many levels: changing medical practices to encourage breastfeeding; educating families, employers and the public about its benefits as well as the needs of breastfeeding mothers and babies; passing legislation that protects the rights of breastfeeding women; shifting the focus of the culture away from formula feeding; and, most important, providing every mother with the day-to-day support she needs to breastfeed successfully.

It's a huge undertaking, and it begins, like so many things, on an intimate, human level.

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Debra Kronschnabel is among the lucky ones on Marinelli's ward. Her twins, Erich and Klarissa, were born full-term in the Hartford Hospital maternity unit upstairs and have been nursing since birth. As a pharmacist, Kronschnabel is well versed in the medical benefits of breastfeeding, and as a third-time breastfeeding mother, she's got plenty of experience. But she has never nursed two babies at once, and she has never dealt with the kind of challenge Erich presents. The Kronschnabel babies were sent down to the NICU at Connecticut Children's Medical Center after Erich's blood sugar dropped. He was stabilized with an intravenous line and supplemental feedings of formula and sugar water, and has recovered enough to have all but the sugar water discontinued. The goal now is to get him nursing frequently and thoroughly enough that, like his sister, he can once again be breastfed exclusively. Marinelli already spent some time this morning successfully working with Kronschnabel and Erich, and now she's back for round two.

"I've been surprised how much support I've needed," says Kronschnabel, who lives in Canton. "I think I've had four sessions with lactation consultants - extended sessions - and this is an experienced mother. ... There was a time when I thought, `Is this all worth it? Maybe it would be better if he didn't breastfeed.' I think the difference between sticking it out and giving it up is having [the staff] here for support."

A few generations ago, women like Kronschnabel would have been helped by mothers, aunts, sisters or friends experienced in breastfeeding. But the advent of formula feeding in the last century - fueled by the regimentation of postpartum care, the entry of women into the workforce and intensive marketing by manufacturers - has interrupted the age-old flow of wisdom and left most women without a natural network of breastfeeding support. Kronshnabel's mother, Sandy Figueroa, who is with her at the hospital today, says she was discouraged by medical staff from breastfeeding her own children. She did manage to nurse one of the four for a few months. "When it works, it is just wonderful, and so much easier," she says. But she has little expertise to offer her daughter today.

Fair-skinned and freckled, with shoulder-length, blond hair, Kronschnabel, 35, settles into a large, upholstered nursing chair, unbuttons her denim shirt, unhooks the front of her nursing bra, and brings Erich to her breast. She is skeptical of the effort. In the couple of hours since their last nursing session, Erich was circumcised, and he is so exhausted from crying that Kronschnabel knows even the scent of his mother and the feel of her nipple against his mouth are unlikely to rouse him.

But Marinelli has a lot of tricks in her bag. Leaning over the chair facing Kronschnabel, she tickles Erich's feet and sides, and loosens his clothing in an effort to disturb him. Then she lifts him away from the swaddling comfort of his mother's body. Finally, she passes him back to the attending nurse, Laura Miele, who removes the IV needle still taped to the back of his right hand. As Miele peels the tight adhesive, Erich finally begins to cry. His mouth open wide in a scream, he is passed back to his mom and latches on immediately. The nipple in his mouth is all the comfort he was looking for, however, and soon he drifts back to sleep.

Marinelli directs Kronschnabel to squeeze out some milk by gently compressing her breast with her thumb and fingers, but even the taste of a meal has no effect on Erich. Normally, such a sleepy baby would be left alone until he is ready to nurse, but Marinelli can't afford to do that with Erich, who must keep up his food intake. So she switches to plan B. She sends Figueroa to the other side of the room to fetch Klarissa, with the hope that her suckling will create the milk letdown needed to get Erich going. Again, Kronschnabel is doubtful. Klarissa nursed until she was full just an hour ago.

Marinelli proceeds anyway, helping Kronschnabel position Klarissa at her right breast, with Erich on the left and soon both are exhibiting the long, drawing sucks and swallows that indicate real eating. Kronschnabel is amazed. "I didn't think we were going to get him to go."

Three months later, both babies are thriving and Kronschnabel is still exclusively nursing. "You worry, am I doing the right thing or am I not," she says. "Had I not had a professional there backing me and helping me figure out how to work it, and also acting as an advocate with the staff there, I don't think I would have been able to do it."

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When Marinelli arrived at CCMC in 1989, only one in five babies on the unit received any breast milk at all. Now, the rate is close to 70 percent, due mainly to her efforts. On the NICU, even more than in the general population, breast milk is liquid gold, and Marinelli believes providing it is central to her medical mission. Research has shown that just as the composition of breast milk changes as a baby ages, so milk produced by mothers whose babies are born prematurely is markedly different from term milk. It is higher in protein, calories and minerals - all nutrients these fragile infants need in greater amounts. Unlike formula, breast milk and its precurser, colostrum, a yellowish fluid produced by mothers in the first few days after birth, provide antibodies that protect against infection. In fact, there is evidence that mothers visiting the NICU pick up on their skin germs unique to the hospital environment, produce antibodies against them, then pass those antibodies back to their babies through the breast milk. And, especially important for premature infants, breast milk is exceptionally easy for most babies to digest.

The natural rhythms of breastfeeding run counter to the culture of an intensive care unit, however. "NICU's are, by the nature of the beast, very precise places, very scheduled places in terms of what needs to occur with the babies," notes Marinelli, "and that doesn't fit with breastfeeding, which is one of the reasons, I think, that it's been so hard to accept breastfeeding in a lot of NICUs, because you can't feed a baby every three hours and give them an exact number of cc's a feeding when you put a baby to breast." Marinelli's team educates everyone from doctors and nurses to secretaries and cleaning staff - many of whom have never breastfed - as to why accommodating it is worth it.

Ellen Robinson, an obstetrician and gynecologist, sits on the American Academy of Pediatrics' state breastfeeding committee with Marinelli and was closely involved in Hartford Hospital's push to become certified as a Baby Friendly Hospital under UNICEF's breastfeeding promotion program. She believes that in addition to not understanding the process of breastfeeding, parents who formula fed - including health-care providers - wrestle with their own guilt. "My personal opinion is that one of the reasons why this is hard for people is that if you didn't breastfeed your own kids ... there has to be some sort of glitch in your head that says, `If I'm telling everybody this is the right thing to do, then I did something wrong,'" observes Robinson.

Many of the preemies on Marinelli's ward spend weeks taking their mother's milk through a tube in the nose until their swallowing and breathing reflexes are developed enough to suck on a nipple. Traditionally, the next step has been to feed them through bottles while their mothers work on getting them to breast. But some babies who get used to the fast flow of artificial nipples may have trouble with the more elaborate sucking pattern breastfeeding requires. So Marinelli has been trying for several years to introduce finger feeding - in which the milk is delivered to babies through a thin tube taped to the parent's or nurse's finger - and cup feeding, in which the baby sips from a tiny medicine cup. It has been an uphill battle. Though the past and current NICU nurse managers have been "incredibly supportive," Marinelli says, many nurses were concerned there was no data assuring the safety of cup feeding. Not one to give up easily, she did the next logical thing: She conducted her own randomized, controlled study at CCMC. Her research, which has since been published, revealed cup feeding to be as safe or safer than bottle feeding because of its controlled flow.

Marinelli and her colleagues on the lactation support team - nurses Sally Leed and Mary Lussier, who is also a lactation consultant - have made many other changes that support breastfeeding. The CCMC unit now allows parents to visit 24 hours a day and provides space for overnight stays with the baby, along with hospital-grade breast pumps and a huge, commercial freezer for storing expressed milk. Each NICU mother receives a cooler pack in which to carry that milk back and forth from home and a 24-page book that takes her step by step through the process of breastfeeding a preemie. A lactation consultant is always on duty, and the lactation team offers a weekly "milk club" at which mothers can discuss breastfeeding issues. Marinelli has even arranged, in a few rare cases, for infants on the unit to receive donor breast milk from a milk bank, paid for by the family's medical insurance.

Such changes are in line with the guidelines established under UNICEF's international Baby Friendly Hospital initiative. So far, Hartford Hospital is the only institution in the state awarded this status, though Middlesex Hospital in Middletown and Windham Community Memorial Hospital in Willimantic have both begun working toward the designation.

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Marinelli's passion for breastfeeding began with her own experience. Traditionally, medical schools have dealt very little with breastfeeding, and even her subsequent pediatric training in the early 1980s barely grazed the subject. It wasn't until she began to get interested in neonatology as a resident at Children's Hospital National Medical Center in Washington, D.C., that the concept of breast milk as an ideal food was introduced. There, a mentor emphasized its value to premature babies. Marinelli was working 36-hour shifts as a fellow at Children's and her husband was still completing his postdoctoral studies in biochemistry when their first child, Alex, was born. Despite the grueling schedule and a slim six weeks' maternity leave, Marinelli decided to breastfeed. She's still not sure why.

"I didn't have a breastfeeding role model. ... But somehow, I knew that this was the right thing to do." And then, Marinelli says, she fell in love with her baby and fell in love with breastfeeding him.

"By the time I went back to work, I had already decided that I didn't care what it took, I was going to pump milk - plenty of it - and my kids were never going to get formula. And so I would go in with my cooler and pump huge amounts of milk. I found time to when no one else seemed to think there was time to be able to pump," she recalls.

"So I was experiencing it as a mother and learning about it scientifically as a physician ... and it really bothered me that nobody knew" how tremendously valuable it is.

Two years later, she arrived at CCMC, and a year later her son Ethan was born. She breastfed him exclusively for almost two years, as she did Alex and, later, daughters Katie and Caroline, despite her demanding work schedule. With each child, and with each year in the NICU, she became increasingly passionate about her mission.

"I think although in medicine it's probably not always the best thing to take your own personal experience into the way that you practice, because I thought breastfeeding was so wonderful with my own children, I want these other mothers to be able to have that chance, too," says Marinelli. That connection is even more important in the NICU, she notes, where the technology can be overwhelming and so little is under the parents' control. Breastfeeding is the one thing they - and they alone - can do for their babies.

"No matter how many times I do it, I get shivers up my back when I get a little, tiny preemie to breast, and the mother's face lights up," says Marinelli. "I think about all the millions of years of evolution - that we got to where we are because we were fed our mothers' milk."

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Carla Holzer is waiting for Marinelli in the center of the NICU, perched on a stool between the bassinets that house her twin daughters. Her only children, Sydney and Savannah, were born seven weeks ago, and Holzer, of Glastonbury, has been expressing breast milk for them ever since. Recently, the more frail of the two developed an acute sensitivity to cow's-milk protein. Holzer has religiously followed the prescribed dairy-, whey- and peanut-free diet for two weeks now, but Savannah is still having trouble tolerating her mother's milk. The doctor on duty this past weekend switched her to a prescription hypoallergenic formula, and though the other twin, Sydney, is thriving, Marinelli knows Holzer has been thinking hard about whether she wants to continue breastfeeding.

A petite, energetic woman with straight brown hair pulled up in a high ponytail, Holzer, 33, is dressed today in gray capris and a pale blue sweater set. A slender silver chain around her neck bears two tiny female figures. Her manner is eager and anxious, as though she is both dreading and longing for this conversation. Marinelli pulls up a chair.

"You know what, Doctor, I've tried," Holzer begins quickly. "I'm very emotional, and I've just decided it's not working for me - and a lot of reasons why, not just the dairy thing, but just I'm feeling torn because I feel like I'm giving too much of myself to her" - she motions toward Sydney, asleep to her left - "and not enough to her" - she sweeps her hand to the right, toward Savannah. "Maybe it's different because I have twins," she rushes on. "I don't know. I don't know. It's very emotional. I never realized it would be this hard to make a decision. ... It might be different if Savannah was the one I could breastfeed, because she's so much smaller and she's having a harder time. I would feel like, yup, I gotta do it. With [Sydney], I just don't feel like, `I gotta do it.'"

"We talked all along about this being something that has to be right for you," Marinelli reassures her. "You've done a great job."

"It doesn't feel like it, though, sometimes," says Holzer. "That's the hardest thing about it. For days now I've been so torn up about it. You know, you do, you feel like a loser. I feel like I'm not a good mom."

"Nope," says Marinelli. "You have worked really hard for these girls. ... You're important in this; I've told you that before. It's the way the family's gonna work. And if you do it because you feel like you have to, and you're feeling all these emotions, that's not good for you.

"Is your husband OK with this?" Marinelli asks.

"Yeah," says Holzer. "I think he's a little disappointed. That was part of it, because I feel like I'm letting him down; I'm letting the whole family down. ...

"It's obviously my choice, but it doesn't make it any easier," Holzer says later, after Marinelli has gone.

Marinelli says, "I have to respect where she is. Any mother who tries [to breastfeed] deserves my respect, and any mother who makes a conscious decision and doesn't want to deserves my respect as well."

She says Holzer's emotional response is typical. "Any mother when she stops breastfeeding has that," she says. "We describe it as being guilt, but I think it's more mourning a loss of a very special relationship, and for our moms it may be even more intense, because for most of the hospitalization, it's the part that they can do, and when they say, `I can't' or `I don't want to do this any more,' it's very tough for them."

Holzer's husband, Frank, says the depth of the breastfeeding bond was clear the first time Carla got her babies to latch on. "To see her face light up ... I got a little emotional," he recalls.

But ultimately, he says, his wife "had put herself on a maternal pedestal that was very difficult for anyone to maintain."

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Whether or how much to encourage women who are ambivalent about breastfeeding is a sensitive subject for advocates, who are often accused of pressuring overwhelmed new mothers. But Marinelli sees a big difference between pressure and education. Every parent, she believes, has the right to make decisions based on accurate information. Offering that information at the right time - in a way that effectively counters the misconceptions that pervade our formula-feeding culture - is the trick. Equally critical is providing moral support. Feeding difficulties can strike at the very core of a parent's sense of competence - her ability to nurture her child - and become the focus of all of a mother's feelings of inadequacy and stress.

One challenge in boosting confidence is that many of the health-care professionals mothers turn to with breastfeeding problems aren't very knowledgeable themselves. Stratford pediatrician Christina Smillie began to specialize in lactation by accident, after she breastfed her own child and found her colleagues constantly referring cases to her. She decided to devote her practice exclusively to the subject after The Wall Street Journal ran a front-page piece in 1994 about a breastfeeding baby who was brain-damaged by dehydration. The piece "made it sound as though breastfeeding was really dangerous and a baby could just inexplicably starve," Smillie remembers. It was clear to her from the details provided, however, that the mother had repeatedly received incorrect advice from her pediatrician's office. "That just really got me that this terrible thing was happening. ... I realized myself and my own colleagues were part of the problem."

Smillie says the psychological support she offers patients is right up there with the medical advice. As Americans, "we don't believe that our breasts work," she says. They have become such a pervasive sex symbol that "we didn't grow up even thinking what their purpose is." She has observed that women raised in breastfeeding cultures outside the U.S. will matter-of-factly work through significant difficulties on their own before seeking her help, while women who have grown up here may be overwhelmed by even minor challenges.

Even mothers who make it through the physical barriers may give up breastfeeding because of the social and emotional ones. Donna Chapman conducted focus groups with Hartford-area mothers when the Hispanic Health Council launched its breastfeeding marketing campaign two years ago. She found the main reasons women chose not to breastfeed or stopped breastfeeding early were embarrassment about nursing in public and a perceived lack of support from others. Some of those feelings are well founded, as Dina Tantimonaco can attest. Her encounter with a Milford police officer in 1996 sparked the state's first breastfeeding legislation.

Tantimonaco was 30 and venturing out for the first time with her first baby, 3-week-old Brianna, when she was approached by a police officer while discreetly nursing her daughter in the front seat of her Ford Blazer, the only vehicle in a secluded parking lot. "I notice you're breastfeeding your daughter, and you're not allowed to do that in public," she remembers him saying. "You need to move your car, and you need to go home and do that."

"I couldn't believe what I was hearing. I was in shock," Tantimonaco recalls. "So I can't stay here for five minutes and feed her and then go home?" she asked. "Not in my parking lot," was the answer. "He said to me, `What is the worst thing that's going to happen to your daughter if you stop breastfeeding her right now?' And I said, `Well, she'll probably frantically cry the whole way home.' And he said, `Then you should just go home, and if you continue to fight this with me ... if you don't get out of my parking lot and stop doing that, I'll have no choice but to arrest you for indecent exposure.' I was not indecent at all. ... My breast was completely covered."

She and Brianna went home, both in tears, and the next day she visited the police station to complain. "They didn't care, or they didn't know what to do about it," she says. So she called her local paper to file a small letter to the editor, and to her surprise the story ended up instead making headlines across the state. "I was just a regular mom who had a bad experience," Tantimonaco says. But because she chose to speak up, "it sparked a national debate because there was no law at the time in our state for the right to breastfeed. What they said was he was actually within his rights as an officer to kick me off the premises. ... It just made me very saddened and confused and angry that they had the authority to do that to a woman who just wanted to nurse her baby."

She contacted her state representative, James Amann, a Democrat. "I asked him ... `What can I do so that I never have to worry about this again?'" Tantimonaco remembers. Her question sparked a yearlong fight to pass Connecticut's first breastfeeding legislation, assuring mothers the right to nurse their babies in public or private. Along the way, Tantimonaco heard countless stories from other women who had been similarly harassed. She also was introduced to a broad community of breastfeeding advocates she had never known existed. Among them was Smillie, in whose office she ultimately worked for four years.

That job nurtured Tantimonaco's breastfeeding relationship in another way, by allowing her to bring Brianna, and then son Joey, to work with her. It's a luxury few working mothers enjoy. Many women face workplaces where breastfeeding is unfamiliar and misunderstood and where requests for even small accommodations are met with resistance or ridicule. Often, mothers end up weaning their infants early in order to avoid the issue entirely, or because of their own misconceptions about the time and effort involved. In truth, all a mother needs to continue breastfeeding while away from her child is a breast pump with which to express milk and a private place in which to use it once or twice a day - along with the confidence to pursue her needs.

In 2000 the state breastfeeding committee teamed up with academy of pediatrics lobbyists, Amann and, through Marinelli, lobbyists from Connecticut Children's Medical Center to introduce a second bill that would address the difficulties nursing mothers face in the workplace. Erica Correa of New Britain was among those who testified at the statehouse.

When Correa returned to work four months after giving birth to her first son, David, her needs were simple. "I worked from 1 p.m. to 6 p.m.," she says. "The only problem I had was I needed to pump once in the afternoon." She quickly discovered, however, that not only was there no private space within the company where she worked as a sales analyst (all the offices had interior windows), but even with 150 employees, her supervisors had never before encountered someone asking for a place to express milk.

"I ended up speaking to all kinds of different managers and finally got clearance to put trade show posters in the windows of one of the offices," Correa recalls. "But because of some traditional hierarchy things, there was only one office I could use, and I was sharing it with other people. So every day there was this discussion as to what Erica's going to do and when she's going to pump, and it was very uncomfortable because my breastfeeding - and, basically, my breasts, which I thought was kind of a sensitive subject - was the topic of office conversation almost every day."

Correa quit her job to take a comparable one with a smaller company that was much more family friendly. "They didn't have a lot of space, but they tried to accommodate any breastfeeding mothers," she says. "And there was a human resources manager who knew what pumping meant." She is still happily employed at the new company, Reflexite in New Britain, and is now on maternity leave with her second child.

Lobbying for the breastfeeding in the workplace act meant having those same sorts of conversations with legislators, many of whom had no idea what expressing milk entails. "People were asking questions like, `Well, why do you have to do it twice?'" says state Rep. Christopher Donovan, a Meriden Democrat, an early champion of the bill and the father of breastfed children. The answer? "Because the breasts fill up with milk again." The incredulous response: "They do?!" Marinelli says they were frequently asked why mothers couldn't just pump in the bathroom - the most unsanitary space in any building. "We'd say, `Would you eat your lunch in a bathroom stall?' and they'd give you this disgusted look. `Well, would you express milk for your baby in a bathroom stall?'"

In the end, after a lot of last-minute lobbying, the bill passed both the House and Senate unanimously and took effect last October. Though it lacks penalties for noncompliance, it is a good beginning, giving nursing mothers the right to express breast milk or breastfeed during breaks without discrimination and requiring employers to provide a private space.

Many companies already have discovered that supporting breastfeeding workers makes good business sense.

Aetna and CIGNA, for example, both offer their employees benefits that include private rooms equipped with professional-grade breast pumps, generous break time, flexible work schedules and lactation consultation. In 2001, Aetna calculated that its investment returned three times the savings in reduced absenteeism and lower health-care costs for breastfeeding mothers and babies. CIGNA's program has been honored by the nonprofit Healthy Mothers, Healthy Babies Coalition and received the C. Everett Koop National Health Award in 2000.

A commitment to employees does not always translate to a commitment to customers, however. Of the nine health plans Smillie's office accepts, so far only one, ConnectiCare, covers visits with a lactation consultant. Even mothers of preemies, for whom breast milk is especially important, frequently find themselves having to fight for coverage of quality breast pumps and lactation support.

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Over the past year, Marinelli and more than a hundred professional and lay people interested in breastfeeding have formed the Connecticut Breastfeeding Coalition. It is a novel, and at times uneasy, collaboration among advocates of many different orientations. While they struggle to chip away at the obstacles to breastfeeding, many remain systemic.

The U.S. lags behind other industrialized and developing countries in maternity leave, for example, which can be critical in establishing a solid breastfeeding relationship. And 20 years after the fact, the U.S. remains one of only seven nations in the world that have not taken a single step toward approving the World Health Organization's International Code of Marketing of Breastmilk Substitutes, sharing company with the likes of Somalia and Moldova. The code, already partially or entirely in force in much of Europe and South America, forbids the advertising of infant formula directly to the public, bans the distribution of free samples and coupons, and requires warning labels on every package. Not only is formula still marketed directly to consumers in the U.S., but often it is done with the direct help of hospitals and health care providers, who pass on free samples and informational packets to patients.

Margaret McLeran learned firsthand just how important these handouts are to formula manufacturers when Hartford Hospital moved to ban them at the start of its efforts to become Baby Friendly. "I got quite a lot of pressure from the Mead-Johnson representatives," says the pediatrician who chaired the hospital's lactation committee. "They went and polled the community pediatricians and then came back with that evidence." McLeran says she and her team had top-level support from hospital administrators, however, and ultimately got formula advertising and samples banned within the hospital. The hospital also decided to distance itself from formula companies, which were building a customer base at birth through the hospitals, and began paying full price for the product used by its patients.

It's a different story for the U.S. government, however, which continues to receive billions of dollars worth of discounted formula every year from manufacturers to distribute to low-income mothers through the Women, Infants and Children program. It's clearly a critical outlet for formula companies, which reward the federal government annually with rebates totaling as much as two-thirds the value of the formula involved.

WIC was launched in 1974, when breastfeeding rates were low nationwide, notes Susan Jackman, WIC nutrition coordinator for Connecticut. "The reality was that babies were drinking formula," she observes, so it was included in the food package. With frequent office visits required, and half the nation's children served by the program, WIC is in a prime position to reach out to pregnant women. Federal regulations now require that every WIC mother be informed about breastfeeding's advantages and encouraged to breastfeed, and a number of Connecticut regions offer special counselors and breastfeeding support groups. Yet WIC breastfeeding rates continue to fall well below national and state averages at every stage.

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It's a Thursday evening, and Marinelli is sitting around the kitchen table of her South Glastonbury home with her family. Her first day off this week featured a host of errands and a meeting of Katie's Brownie troop, which she co-leads. Now, it's after 8:30 on a school night, and Katie, 8, and Caroline, 5, should be heading to bed. But there's a visitor present, and Marinelli just can't stop talking about her favorite subject.

As the conversation progresses, her voice becomes more animated. Ethan, 12, is listening intently, puzzling out the issues and peppering her with thoughtful questions. Of all the children, Marinelli says, he is the most passionate about breastfeeding. He once asked her, with great concern, "Mom, what if when I grow up, the woman I fall in love with doesn't want to breastfeed?" She assured him they would talk to her together. (Smillie says she had a similar experience with her own son, now 17, who reported asking his first girlfriend whether she planned to breastfeed.)

Marinelli is launching into a description of her next project - setting up an outpatient breastfeeding clinic for mothers whose babies have been in the NICU - when her husband, Mark Bamberger, lays his hands gently on her shoulders. "Kathie," he suggests softly, "maybe you should just, like ..."

"Leave her alone?" Marinelli asks, smiling at her guest.

"Well, I mean, I can tell you're into this breastfeeding avenger [thing]," he offers.

"I'm almost done," she promises. "I'm not the avenger! This is the next phase in my plan at work. There's no secret about it."

In truth, Marinelli says, Bamberger has been her greatest supporter - from her first breastfeeding experience through her new activism - never complaining about the demands her schedule places on him and the rest of the family. "I couldn't do what I do if I had a different husband," she says. "I think about how much hard work he does so I can do these things. He never says no." When she got a call this spring from a co-worker who was having difficulty breastfeeding her new baby, for example, it was Bamberger who encouraged her to make her first house call, even though they were just sitting down to dinner. "I said, `If I don't go, I think she's going to quit,'" Marinelli recalls. "And he said, `Go. You need to go.' And I went, and she's breastfeeding!"

It was a response born of experience. Marinelli once placed just such a call to a nurse on her unit while struggling to breastfeed her youngest, Caroline. "Because I was the mother and not the lactation consultant, I couldn't recognize what the issues were," she remembers. "I called her and said, `I don't know what's going on here, but if someone doesn't help me, I'm quitting,' and she said, `YOU?! You breastfeed forever!'" The nurse came right away, and Marinelli went on to breastfeed for close to two years.

Bamberger has done his share of advocacy, as well, encouraging his pregnant co-workers to breastfeed, offering them Marinelli's phone number for support and gathering information about Pfizer's employee lactation programs to be presented to the state legislature.

Though Marinelli's many commitments generally don't add to the family's bottom line, Bamberger believes in them wholeheartedly. "That's her passion. That's her mission in life," he says. "I respect that and admire that ... That's what's important - you do something you love."

Charlotte Meryman is a writer in Williamsburg, Mass., and edits a newsletter for breastfeeding mothers. She wrote "The Jimmy File," a Northeast cover story in 2001.